The algorithms below were created by Vijay Bhandari in 2009 for a noon conference on evidence-based treatments for hypertension in different clinical settings.

Hypertension Treatment Algorithm #1 (for uncomplicated hypertension)

• Goal BP <140/90
• If CAD risk equivalent or Framingham 10-year CV risk >10%, consider BP goal <130/80
• CAD risk equivalents include CVA, carotid artery disease, PVD, and AAA
• For algorithms below, titrate doses up q2-4 weeks to meet BP goal. If still not at goal, go to the next number and add that medication. You do not need to maximize doses of each medication, as combinations of medications are often more effective than single medications, even at higher doses.

1. Chlorthalidone (or HCTZ if planning combo pill) 12.5 -> 25
2. Add lisinopril 10 -> 20 -> 40. Titrate q2-4 weeks to BP goal.
3. Add amlodipine (DHP CCB) 5 -> 10. Titrate q2-4 weeks to BP goal
   • or nifedipine XL (DHP CCB) 30 -> 60 -> 120
   • or diltiazem ER (nonDHP CCB) 180 -> 300 -> 420
   • or verapamil SR (nonDHP CCB) 120 -> 240 -> 360
4. Consider:
   • spironolactone 25 -> 50 (avoid if Cr>2 or K>5)
   • metoprolol succinate 50 -> 100 -> 200 or metoprolol tartrate 25 -> 50 -> 100 BID (avoid if using diltiazem or verapamil)
   • other subclass of calcium channel blocker not already used
   • hydralazine 20 -> 50 -> 100 bid
   • clonodine 0.2 -> 0.2 -> 0.3 -> 0.4 bid
   • clonodine patch 0.1 -> 0.2 -> 0.3

Hypertension Treatment Algorithm #2 (for patients with DM and/or CKD, especially with proteinuria)

• Goal BP <130/80
• If proteinuria >1g/day, consider BP goal <125/75
• For algorithms below, titrate doses up q2-4 weeks to meet BP goal. If still not at goal, go to the next number and add that medication.

1. Lisinopril 10 -> 20 -> 40. Titrate q2-4 weeks to BP goal. If patient has albuminuria >500mg/d, even if BP at goal, consider uptitrating lisinopril to 80 or adding losartan 25.
2. Add chlorthalidone (or HCTZ if planning combo pill) 12.5 -> 25
   • consider furosemide 10 -> 20 -> 40 bid or torsemide 2.5 - 5 -> 10 if GFR <30
3. Add diltiazem ER (nonDHP CCB) 180 -> 300 -> 420 or verapamil SR (nonDHP CCB) 120 -> 240 -> 360
   • or amlodipine 5 -> 10
   • or nifedipine XL (DHP CCB) 30 -> 60 -> 120
4. Condider adding:
   • spironolactone 25 -> 50 (avoid if Cr>2 or K>5)
   • metoprolol succinate 50 -> 100 -> 200 or metoprolol tartrate 25 -> 50 -> 100 BID (avoid if using diltiazem or verapamil)
   • other subclass of calcium channel blocker not already used
   • hydralazine 20 -> 50 -> 100 bid
   • clonodine 0.2 -> 0.2 -> 0.3 -> 0.4 bid
   • clonodine patch 0.1 -> 0.2 -> 0.3

Hypertension Treatment Algorithm #3 (for patients with CAD and stable angina or h/o MI and normal LV systolic function)

• Goal BP <130/80
• If patient meets above criteria and has comorbid diabetes and/or proteinuric CKD, then clinical judgment should determine which algorithm to follow. In general, a more recent MI (within 3 years) or exercise-limiting anginal symptoms would warrant stronger consideration of this algorithm.
• For algorithms below, titrate doses up q2-4 weeks to meet BP goal. If still not at goal, go to the next number and add that medication.

1. Metoprolol succinate 50 -> 100 -> 200 or metoprolol tartrate 25 -> 50 -> 100 BID. Titrate to HR goal 55-70 as BP tolerates.
   • if at this point angina remains inadequately controlled at 2-4 weeks, add amlodipine 5 -> 10 or nifedipine XL 30 -> 60 -> 120.
2. Add lisinopril 5 or 10
   • if at this point angina remains inadequately controlled at 2-4 weeks, add amlodipine 5 -> 10 or nifedipine XL 30 -> 60 -> 120.
3. Increase lisinopril to 10 -> 20 -> 40
4. Add chlorthalidone (or HCTZ if planning combo pill) 12.5 -> 25
5. Add amlodipine 5 -> 10 or nifedipine XL (DHP CCB) 30 -> 60 -> 120
6. Condider adding:
   • spironolactone 25 -> 50 (avoid if Cr>2 or K>5)
   • hydralazine 20 -> 50 -> 100 bid

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This page has been edited 12 times. The last modification was made by - tairoe on Feb 16, 2011 5:08 pm